Provider Demographics
NPI:1093231581
Name:XU, YISHAN (LCP)
Entity Type:Individual
Prefix:
First Name:YISHAN
Middle Name:
Last Name:XU
Suffix:
Gender:F
Credentials:LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:885 N SAN ANTONIO RD STE O
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-1341
Mailing Address - Country:US
Mailing Address - Phone:650-434-2563
Mailing Address - Fax:
Practice Address - Street 1:885 N SAN ANTONIO RD STE O
Practice Address - Street 2:
Practice Address - City:LOS ALTOS
Practice Address - State:CA
Practice Address - Zip Code:94022-1341
Practice Address - Country:US
Practice Address - Phone:650-434-2563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-16
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29376103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical